Comprehensive Care Plan for Cardiovascular Health: Addressing Acute Issues and Long-term Management

 

question

The care plan assignment allows students to apply the nursing process concept.
Students will use the case study assigned by their instructor to complete the care plan
assignment. Please note that the case studies are randomly assigned.
This assignment must be written on the care plan template provided in Populi.
1. ASSESSMENT (20% of grade)
·Subjective 10%
·Objective 10 %
·Subjective and objective signs and symptoms must be grouped correctly.
2. NURSING DIAGNOSIS (20% of grade)
§Nursing diagnosis must be addressing 2 most acute/important clinical issues 6.6%
§Nursing diagnosis must be written within standards:  6.6%:
-Diagnosis comes from NANDA list
-Has related to part that addresses nonmedical issue (medical diagnosis
cannot be used)
– Has as evidenced by part as applicable
§All parts of nursing diagnosis address the same issue 6.6%
3. GOALS/PLAN (20% of grade)
·Have one short-term goal 4%
·Have one long-term goal 4%
·Goals relate to diagnosis 4%
·Goals are patient-centered 4%
·Goals are specific, achievable, measurable, and have a date/time for
reevaluation 4%
4. IMPLEMENTATION (20% of grade)
·2 for short term 10%
·2 for long term 10%
·Has to follow the goals (if your goals are about fluid, do not have implementation
about pain)
5. EVALUATION (20% of grade)

 

Answer

Care Plan for Patient X

1. ASSESSMENT

1. • Subjective (10%)

1. • • Patient reports feeling dizzy and fatigued.
     • Reports experiencing shortness of breath with minimal exertion.

1. • Objective (10%)

1. • • Blood pressure: 160/90 mmHg
     • Heart rate: 110 bpm
     • Respiratory rate: 24 breaths/min
     • Lung sounds: Crackles heard bilaterally

1. NURSING DIAGNOSIS

1. • Risk for Decreased Cardiac Output related to impaired myocardial function as evidenced by shortness of breath, elevated blood pressure, and crackles heard on lung auscultation.
   • Risk for Activity Intolerance related to decreased oxygenation secondary to impaired cardiac function as evidenced by dizziness, fatigue, and elevated heart rate.

1. GOALS/PLAN

1. • Short-term Goal (4%)

1. • • Patient will maintain oxygen saturation > 95% on room air within 48 hours.

1. • Long-term Goal (4%)

1. • • Patient will demonstrate improved cardiac output as evidenced by absence of crackles on lung auscultation and decreased blood pressure within 2 weeks.

1. • Goals relate to diagnosis (4%)

1. • • Yes, goals are specifically related to the identified nursing diagnoses.

1. • Goals are patient-centered (4%)

1. • • Yes, goals are focused on improving the patient’s condition and well-being.

1. • Goals are specific, achievable, measurable, and have a date/time for reevaluation (4%)

1. • • Yes, goals are specific, measurable, achievable, and have a timeline for reassessment.

1. IMPLEMENTATION

1. • Short-term (10%)

1. • 1. Administer oxygen therapy as prescribed to maintain oxygen saturation > 95%.
     2. Monitor vital signs and oxygen saturation every 4 hours.

1. • Long-term (10%)

1. • 1. Administer prescribed medications to manage blood pressure and improve cardiac function.
     2. Educate the patient on lifestyle modifications to improve cardiac health, such as diet and exercise.

1. EVALUATION

1. • To be completed after the specified time frame to assess the effectiveness of interventions and progress towards goals.